Using Health Insurance Form

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Using Health Insurance?
Follow the simple steps below before your first visit in our office. It’s as easy as 1, 2, 3! Ask
your insurance representative any additional questions you may have.
1. Call the Customer Service/Member # on your insurance card. Follow the automated steps to
receive your member benefits.
2. What is Insurance Representatives name: ________________________________________________________
a. Date: ____________________________________ Time: ______________________________________________
3. My name is ______________; I am calling to see what my chiropractic benefits are.
4. I will be seeing Dr. Heather Yost with Yost Family Chiropractic. Is she in or out of network?
5. Is there a deductible? {YES} {NO}
(circle one)
a. If YES, what is my deductible amount? _____________________________________________________________
b. How much has been applied to my deductible? _____________________________________________________
6. What are my chiropractic benefits?
a. Co-Insurance: _______________________________________________________________________________
b. Copay: ______________________________________________________________________________________
7. Are there any policy limitations such as a dollar amount or number of office visits?
_______________________________________________________________________________________________________
a. If YES, has anything been already applied to these limitations? ____________________________________
8. What is my effective date? __________________________________________________________________________________
9. Is authorization required for my plan? _______________________________________________________________________
10.
{YES} {NO}
Are my covered benefits based on medical necessity?
(circle one)
11. Provide your insurance representative with the following codes. Find out if they have the same
chiropractic benefit quoted above or if they have a separate benefit.
a. CPT Code 72010 (X-Ray): ___________________________________________________________________________
b. CPT Code 99202 (Exam): ___________________________________________________________________________
c. CPT Code 97014 (Muscle Stimulation Therapy,): __________________________________________________
d. CPT Code 97112 (ART, Muscle Therapy): __________________________________________________________
e. CPT Code 29200 (Kinesotape Strapping): __________________________________________________________
Consultations are free of charge and all fees will be discussed before any services are rendered
PS – Have an HSA or FLEX account? Great news! Take advantage of reduced fees (sometimes even better than
your insurance benefits!) by using these tax savings accounts!
Patient Print Name: _____________________________ Patient Sign: ________________________________ Date: _______________

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